I have been advised of the procedures for seeking medical treatment for my alleged work-related injury/illness. By signing below, I am choosing to refuse medical treatment for the above-referenced injury. I understand that my signature indicates my refusal of the medical treatment that has been offered to me and that I am completely responsible for seeking medical attention on my own and will pay for any subsequent bills associated with this medical treatment. I acknowledge that I am fit to return to full-time duty at work and the injury/illness will not affect my job performance or attendance at work. I further understand that my signature on this refusal form may result in loss of benefits under the Workers’ Compensation Act.